Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options. / Infarto hemisférico maligno de la arteria cerebral media. Consideraciones diagnósticas y opciones terapéuticas.

INTRODUCTION: Malignant hemispheric infarction (MHI) is a specific and devastating type of ischemic stroke. It usually affects all or part of the territory of the middle cerebral artery although its effects may extend to other territories as well. Its clinical outcome is frequently catastrophic when only conventional medical treatment is applied. OBJECTIVE: The purpose of this review is to analyse the available scientific evidence on the treatment of this entity. DEVELOPMENT: MHI is associated with high morbidity and mortality. Its clinical characteristics are early neurological deterioration and severe hemispheric syndrome. Its hallmark is the development of space-occupying cerebral oedema between day 1 and day 3 after symptom onset. The mass effect causes displacement, distortion, and herniation of brain structures even when intracranial hypertension is initially absent. Until recently, MHI was thought to be fatal and untreatable because mortality rates with conventional medical treatment could exceed 80%. In this unfavourable context, decompressive hemicraniectomy has re-emerged as a therapeutic alternative for selected cases, with reported decreases in mortality ranging between 15% and 40%. CONCLUSIONS: In recent years, several randomised clinical trials have demonstrated the benefit of decompressive hemicraniectomy in patients with MHI. This treatment reduces mortality in addition to improving functional outcomes.

Predictors of mortality and poor functional outcome in severe spontaneous intracerebral hemorrhage: a prospective observational study.

OBJECTIVE: To analyze mortality and functional outcome in patients with severe spontaneous intracerebral hemorrhage (ICH), and identify the clinical characteristics, radiological findings and therapeutic procedures predictive of mortality in the Intensive Care Unit (ICU) and during hospitalization, as well as of poor functional results at 6 months. DESIGN: A prospective, observational study was carried out. SETTING: Neurocritical Care Unit of a university hospital. PATIENTS: Patients diagnosed with ICH were included over a period of 23 months. VARIABLES OF INTEREST: Demographic characteristics, cardiovascular risk factors, regular medication, laboratory test parameters, cranial CT findings, therapeutic procedures and outcome data. INTERVENTION: None. RESULTS: A total of 186 patients with ICH met the inclusion criteria. Surgery to evacuate ICH was performed in 25.8% of the patients. The mortality rate was 46.7%. The modified Rankin score at 6 months was 5 (RI: 4.6). Multivariate Cox regression analysis showed the presence of diabetes, prior anticoagulation, as well as APACHE II severity and the type of bleeding on the cranial CT scan to be predictors of mortality and poor functional outcomes. On the other hand, neurosurgical procedures and intracranial pressure (ICP) monitoring were associated with better outcomes. CONCLUSION: The presence of comorbidities such as diabetes, or previous anticoagulation, as well as the CT findings were associated to poorer outcomes. In contrast, ICP monitoring and early neurosurgery were predictive of longer survival and better functional outcomes.

[Intracranial pressure monitoring in severe traumatic brain injury: A different perspective of the BestTrip trial]. / Monitorización de la presión intracraneal en el traumatismo craneoencefálico grave: otra visión del Best Trip trial.

The present study outlines a series of questions and reflections upon the recent publication of Chesnut et al., who compared 2 approaches to the treatment of intracranial hypertension (ICH) in severe head injuries: one with and the other without intracranial pressure monitoring (ICP). The authors concluded that no improved outcome was observed in the treatment group guided by ICP monitoring. The main concerns relate to the degree of training of the physicians involved in the monitoring and management of ICH in the ICP group, as well as to the possible inter-observer variability in interpreting the CT scans, the capacity of clinical signs to guide the treatment of ICH, and the suitability of randomization. The analysis of this trial should not be taken to suggest the futility of ICP monitoring but rather the need to correctly use the information afforded by ICP monitoring, with emphasis on the importance of the definition of alternative methods for non-invasive monitoring.

Effect of exercise on circulating levels of brain-derived neurotrophic factor (BDNF) in overweight and obese subjects.

Exercise increases the expression of brain-derived neurotrophic factor (BDNF) in rodents and in healthy humans. Its relationship with weight loss and improvement in metabolic parameters, in obese human subjects, has not been elucidated. The aim of the study was to evaluate the effect of an aerobic exercise program on circulating levels of BDNF in overweight and obese subjects. We measured anthropometric and metabolic parameters in 15 male and female nondiabetic outpatients (age 38.3±9.5 years, BMI 27-35 kg/m2), before and after 30 sessions of aerobic exercise (3 sessions per week). Plasma (p), serum (s), and platelet (plat) BDNF concentrations were measured at basal condition and after completing 15 and 30 sessions of exercise. Subjects were advised to continue their usual food intake. A significant decrease in weight, BMI, waist circumference, diastolic blood pressure and total cholesterol was observed at the end of the study (p<0.02). Serum and platBDNF showed a significant increase during the training period (p=0.005 and 0.04 respectively). However, pBDNF showed no significant increase. Area under the curve of glucose at baseline, was inversely correlated with sBDNF (r= - 0.53, p=0.04) and platBDNF (r= - 0.6, p=0.01) after session 15. Also, platBDNF was correlated inversely with post load insulin and HOMA2-IR at the end of the training program (r= - 0.53, p=0.03 and r= - 0.52, p=0.04, respectively). In overweight and obese subjects, serum and platBDNF levels increase after 30 sessions of aerobic exercise. This is accompanied with the improvement of anthropometric and metabolic parameters and modest weight loss.

Genetic diversity and new genotyping scheme for fish pathogenic Streptococcus agalactiae.

UNLABELLED: This study aimed to assess the genetic diversity of fish isolates of Streptococcus agalactiae by capsular serotyping, MLST and the pattern of selected virulence genes. Forty-six isolates from Nile tilapia and Amazon catfish were screened by PCR for the twelve virulence genes. The molecular capsular type and sequence type (ST) were determined. Two capsular types (Ia and Ib) and four STs (103, 260, 552 and 553) were identified. The ST-552 and ST-553 represent new allelic combinations. Variable results were found for the genes gbs2018-6, lmb, hylB and cylE. The combined evaluation of serotype, sequence type and pattern of the presence or absence of cylE and hylB allowed the classification of isolates into nine genetic profiles (I-IX). The proposed scheme showed higher discriminatory power and was able to detect evolutionary events missed by MLST analysis. This study provides new information about the genetic diversity of fish pathogenic Strep. agalactiae, and the proposed scheme was shown to be an improved approach to genotyping these strains. SIGNIFICANCE AND IMPACT OF THE STUDY: This study showed that critical genetic events in Streptococcus agalactiae isolates pathogenic for fish have been missed by serotyping and multilocus sequence typing (MLST). A proposed genotyping scheme based on the evaluation of concatenated data from serotyping, MLST, and the presence/absence of virulence genes was created, and this was able to detect old and recent evolutionary events. It provided a better understanding of the genetic diversity of Strep. agalactiae populations from fish and will contribute to future studies of the molecular epidemiology, pathogenesis and evolutionary aspects of this pathogen.

Ten physiological commandments for severe head injury.

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.

Ten physiological commandments for severe head injury. / Diez mandamientos fisiológicos a lograr durante el traumatismo craneoencefálico grave.

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.

[Radiological and functional results in high-energy tibial plate fractures]. / Resultados radiológicos y funcionales en fracturas de platillo tibial de alta energía.

INTRODUCTION: The tibial plateau fractures due to high-energy mechanisms are serious injuries that occur on a load bearing joint. These are difficult to approach because, also affect the bone structure of the leg, they usually have associated soft tissue injuries. OBJECTIVE: To evaluate the radiological and functional results of high-energy tibial plateau fractures with a minimum follow-up of one year. MATERIAL AND METHODS: Retrospective, observational and multicenter study. Analysis of radiological and functional outcomes in the treatment of high-energy tibial plateau fractures, treated by open reduction and internal fixation (ORIF) between 2014 and 2019. RESULTS: 54 fractures treated by ORIF. Follow-up one year. 98.1% consolidation in 13 weeks on average. 83.4% without alterations of the axis in the coronal plane. 74% without postoperative joint widening. Functional scores: Lysholm 82.1 average points and Oxford Knee Score (OKS) 39.5 average points. CONCLUSION: The joint range of motion was reduced after a high-energy tibial plateau fracture, but with good functional results. The less off axis and less post-operative radiographic widening, the better results are obtained.

INTRODUCCIÓN: Las fracturas de platillo tibial por mecanismos de alta energía son lesiones graves que ocurren sobre una articulación de carga. Son difíciles de abordar, ya que además de afectar la estructura ósea de la pierna suelen tener lesiones de partes blandas asociadas. OBJETIVO: Evaluar los resultados radiológicos y funcionales de las fracturas de platillo tibial de alta energía con un mínimo seguimiento de un año. MATERIAL Y MÉTODOS: Estudio retrospectivo, observacional y multicéntrico. Análisis de los resultados radiológicos y funcionales en el tratamiento de fracturas de platillo tibial de alta energía tratadas mediante reducción abierta y fijación interna (RAFI) entre 2014 y 2019. RESULTADOS: 54 fracturas tratadas mediante RAFI. Seguimiento un año, 98.1% de consolidación en 13 semanas de promedio, 83.4% sin alteraciones del eje en plano coronal, 74% sin ensanchamiento articular postoperatorio. Escalas funcionales: Lysholm 82.1 puntos promedio y Oxford Knee Score (OKS) 39.5 puntos promedio. CONCLUSIÓN: El rango de movilidad articular se redujo luego de una fractura de platillos tibiales de alta energía, pero con buenos resultados funcionales. Cuanto menor deseje y menor ensanchamiento radiográfico postoperatorio, se obtienen mejores resultados.